Peri-implantitis is a destructive inflammatory process affecting the soft and hard tissues surrounding dental implants.
The soft tissues become inflamed whereas the alveolar bone (hard tissue), which surrounds the implant for the purposes of retention, is lost overtime.
Bleeding on probing is considered normal whilst tissues are healing shortly after implant placement, however, if bleeding is present months or years after placement, inflammation should be suspected. Other features which may be present whilst probing include pus, the presence of a pocket around the implant and/or recession of the gums. The dental professional may also notice swelling and redness of the gums, the latter of which is termed erythema.
Clinically, peri-implantitis involves both inflammation of soft tissues and destruction of bone, therefore, there is usually evidence of both bone loss (assessed by a radiograph) and bleeding when nearby tissues are probed, a common finding for soft tissue inflammation. There has been reports of bone loss without any accompanying sign of soft tissue inflammation. Without evidence of bone loss, the diagnosis is restricted to peri-mucositis.
Despite similarities regarding clinical features and aetiology of peri-implantitis and periodontitis, critical histopathological differences exist between the two lesions.
Plasma cells and lymphocytes dominated among cells in both types of lesions, whereas neutrophil granulocytes and macrophages occurred in larger proportions in peri-implantitis.
Poor plaque control – this highlights the importance of cleaning the tissues around an implant between dental appointments. It is understood that patients sometimes feel discomfort whilst brushing around implants and are advised to speak to their dentist about this. Also, patients may sometimes be unable to access some sites for cleaning.
Lack of regular maintenance therapy. To avoid this, regular dental visits should be arranged to enable early detection and management of peri-implantitis.
The prognosis for implants are significantly higher in those who don’t smoke compared to those who do, therefore patients should be encouraged to quit smoking in order to achieve the best results.
To prevent roughening and damaging of the implant surface, ultrasonic scalers with a non-metallic tip or resin/carbon fiber curettes are used for calculus removal. Conventional steel curettes or ultrasonic instruments with metal tips should be avoided as implant surface can be damaged, and any residual marks increase implant susceptibility to plaque accumulation in the future. Polishing with rubber cups and polishing paste also will help patient in plaque removal.
This is performed in conjunction with mechanical debridement, with application of chlorhexidine digluconate, a potent antiseptic. To achieve positive treatment results, 3–4 weeks of regular administration of chlorhexidine, either in the form of daily rinse (of 0.1%, 0.12% or 0.2%) or as a gel, is necessary. This is also recommended to maintain satisfactory plaque control. Chlorhexidine is shown to significantly improve the mucosal condition in bleeding on probing, probing pocket depth, and clinical attachment level.
Laser beam can be used to disinfect the area.
This approach is aiming to eliminate or at least significantly reduce the pathogens in the submucosal biofilm. An antibiotic targeting gram-negative anaerobic bacteria – e.g. metronidazole or ornidazole is administered during the last ten days of antiseptic treatment, allowing peri-implant infection to be treated successfully and remain stable. Reinfection is subsequently prevented by instituting prophylactic procedures. Alternatively, tetracycline periodontal fibers can be inserted locally for a period of ten days; this creates an environment of sustained high dose of the antimicrobial agent at the affected site for several days. Another method is to use minocycline microspheres in conjunction with mechanical debridement; this has shown to improve probing depths, but the treatment may have to be repeated in future.
Surgical flap management with either (or both) resective and regenerative approaches is only considered if infection is controlled successfully. This treatment is used to restore the bony support through guided bone regeneration, or to reshape the peri-implant soft tissue.This also helps in comprehensive debridement and local decontamination of the affected implant. It is vital to consider the aesthetic and morphological characteristics of the peri-implant lesion when considering resective surgical techniques.
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